ICD-10 THE BASICS PMG, Inc. 700 School Street Pawtucket, RI 02860 P: 401-616-2000 F: 401-616-2001 E: PMGConsulting@gopmg.com 2015, PMG, Inc. All Rights Reserved Agenda Intro ICD-9 vs. ICD-10 ICD Basics (9 & 10) Understanding ICD 10: the book Assigning a code Interesting nomenclature Coding Tips Examples Summary 1
Speaker: Ray Jorgensen, MS, CPC, CHBME Ray Jorgensen is Co-Founder & CEO of PMG, Inc. Responsible for vision creation, C-level relationships, national speaking/consulting engagements, and partner oversight of PMG Consulting, Ray is nationally recognized healthcare expert and sought after speaker having personally trained thousands from all 50 states on coding, billing, and reimbursement in addition to authoring two books and dozens of articles. Ray s health care experience and education is unique in that he was schooled by the payers. Having worked for Blue Cross and Blue Shield as well as United HealthCare Corporation, primarily in professional relations and contracting, Ray has an understanding and perspective on the payer s objectives and process unlike other medical business consultants groomed from the provider side. BA from The College of the Holy Cross (Worcester, MA) MS from Northeastern University (Boston, MA) CPC from the American Academy of Professional Coders (Salt Lake City, UT) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA) Disclaimer 1. The coding guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Priority Management Group, Inc. does not accept any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter has significant financial interest/ relationship with the organization that provides this product/service. 2
ICD-9 vs. ICD-10 Textbook ICD-9-CM Code Totals: 13,500 Chapters: 17 Primarily Numeric ICD-10-CM Code Totals: 68,000 Chapters: 21 All Alpha-Numeric Similarities: Alphabetical Index & Tabular List PCS & CM Similar Nomenclature ICD-9 vs. ICD-10 Structure ICD-9-CM 3 to 5 characters Primary Numeric Except V & E Codes 4 & 5 afford additional specificity Example: 917.6 Splinter, foot/toes ICD-10-CM 3 to 7 characters Character 1 alpha Character 2 & 3, numeric Character 3 to 7, alpha/numeric Example: S90.452A Superficial foreign body, left great toe, initial encounter 3
ICD-9 Usage Guidelines October 1st Effective Date Identify all diagnoses, symptoms, conditions, problems, complaints, or reason for service or procedure List primary condition first, then current/active issues Utilize max characters Probable, suspected, rule out, or questionable diagnoses should not be coded until the diagnosis is confirmed; code symptoms, signs, conditions, test results, or other reasons for the encounter Chronic diseases: report as many times as the patient receives treatment for the condition Ancillary diagnostic or therapeutic service: List diagnosis or problem initiating service first, V code second Surgical Service: Code condition for which service is performed or definitive diagnosis if different DO NOT CODE WHAT NO LONGER EXISTS! ICD to CPT Linkage Example ICD Codes In Order of Provider's Perceived Acuity 1 Otalgia 388.70 2 Cerumen Impaction 380.4 3 Hearing Loss 389.90 4 Strep Throat 034.0 Rendered Services: "Linked" ICD to CPT A 99213-25 Level 3, established patient 1 B 69210 Removal impacted cerumen 2 C 87880 Rapid strep 4 D 92557 Audiometry 3 4
Basics of the ICD Book: ICD-10 s two volumes Alphabetic Index (Vol. 1) Tabular List (Vol. 2) Procedural Code System (Vol. 3) not needed!! The Alphabetical Index Consists of Alphabetical list of terms Corresponding code Additional sections: Index of Diseases and Injury Index of External Causes of Injury Table of Neoplasms Table of Drugs and Chemicals 5
Alpha Index E.g. The Tabular List Structured list of codes Chapters based on body system or condition All in alpha-numerical order Instructional notes and directions Includes Excludes 1 and 2 Status/stage of care (A,D,S) NOTES Placeholders and/or additional digits 6
Tabular List Example ICD Code Assignment Steps Start in the Index Follow instructions Subsets See See also Omit codes DO NOT CODE FROM THE INDEX Locate code in the Tabular List Read all the instructional materials Consult and apply any coding guidelines Confirm and assign the code(s) 7
ICD Code Assignment E.g. 4. Chalazion, right lower eyelid Start with the Index Main terms: Identify Conditions or Injuries Acute Appendicitis: Look under Appendicitis Stress Fracture: Look under Fracture Sub Terms: Under the main terms Indented to the right Lower case letter Not in bold Find Bronchospasm in your Index 8
First step: Identify Main Term Bronchospasm (acute) J98.01 - with - - bronchiolitis, acute J21.9 - - bronchitis, acute (conditions in J20) see Bronchitis, acute - due to external agent see condition, respiratory, acute, due to - exercise induced J45.990 Categories & Subdivision Characters may be a letter or a number All categories = 3 characters If 3-character category with no subdivision 3-character item IS the full ICD code Subcategories: 4 or 5 characters ICD Codes are 3 to 7 characters Subcategory = each level of subdivision Final level of a subdivision = selected code Codes with 7 th character invalid without 7 th 9
Contraception (was V25) Z30: Category Encounter for contraceptive management Z30.4: Subcategory Encounter for surveillance of contraceptives Z30.41 Encounter for surveillance of contraceptive pills Inclusion Term Encounter for repeat prescription for contraceptive pill Default Codes Found in Alphabetical index Code listed next to a main term Default code = Condition most commonly associated with the main term OR Unspecified code for the condition Documented condition without additional detail, assign default code E.g., N80.9 for endometriosis 10
Alpha Index Example Alpha Index Example 11
Concern about Default Codes Similar to unspecified ICD-9 Unspecified exists in ICD-10 but avoidable Because so many options exist Concern some payers may deny unspecified Too early to know for certain but avoidable As always, code & DOCUMENT what you know Crosswalk Examples 12
Multiple Diagnoses One code may capture two diagnoses (E.g. #1) E.g., Flu with digestive issues Other conditions may require two codes (E.g., #2) E.g., Type II diabetic who uses insulin E.g. #1: Influenza with digestive manifestations 13
E.g. #2: Type 2 diabetic with diabetic cataract, patient uses insulin regularly Multiple codes, single condition Code first causal conditions when known Assign as principal when causal condition unknown/not applicable Causal condition known, code the condition as the principal or first-listed diagnosis Multiple codes possible if Sequela Complication codes Obstetric codes, more fully describe condition(s) See specific guidelines for further instruction 14
E.g.: Chronic Pain in right knee Combination Code (1 of 2) Used to classify: Two diagnoses, or Diagnosis with associated secondary process (manifestation) Diagnosis with associated complication Identified by Referring to subterm entries in the Alphabetic Index Reading inclusion and exclusion notes in the Tabular List 15
Combination Code (2 of 2) Assign only combination code when: Code fully identifies diagnostic conditions involved Alphabetic Index so directs Multiple codes NOT used when Code exists which clearly identifies all of the elements documented in the diagnosis Code lacks necessary specificity describing manifestation or complication, Additional code as a secondary code Combo Code Example (1 of 2) Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (1 of 2) Answer, Part 1: H72.91 16
Combo Code Example (2 of 2) Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (2 of 2) Answer, Part 2: H66.3X1 Final Answer: H66.3X1, H72.91 Impending/Threatened Condition (1 of 2) If it did occur: Code confirmed diagnosis If it did not occur Reference Alphabetic Index Determine if condition has subentry term for impending or threatened Reference main term entries for impending or threatened 17
Impending/Threatened Condition (2 of 2) Sub terms listed, assign given code Sub terms not listed Code existing underlying condition(s) Code not condition described as impending or threatened Impending/Threatened Condition Example 18
Acute & Chronic Conditions Patient condition Both acute (sub acute) and chronic Separate subentries in Alphabetic Index Code both with acute (sub acute) code primary Acute & Chronic Example 19
Laterality Some codes indicate Left vs. Right No bilateral code, code each L & R code Side not documented = unspecified Laterality Example 1 20
Laterality Example 2 Code what you know diagnostic tests Results available? Code results No Results, code symptoms/condition 21
Excludes 1 & Excludes 2 Excludes1 REALLY means do not code with main term Excludes2 SHOULD say OK to code also if it exists Excludes 1 & 2 Example 22
Place Holder (X) Character Placeholder = character X X used to allow for future expansion E.g., adverse effect and under dosing (T36-T50) Certain ICD-10-CM = 7 characters i.e., 7th character required for all codes within the category Code requires a 7th character < 6 characters, placeholder X needed Place Holder (X) E.g., #1 23
Place Holder (X) E.g., #2 Place Holder (X) E.g. #3 24
CODING EXAMPLES 1. RUE internally rotated (2 of 2) 25
1. RUE internally rotated (2 of 2) Answer: M99.07 2. Cervical radicular pain (1 of 2) 26
2. Cervical radicular pain (2 of 2) Answer: M54.12 3. Low back strain/pain (1 of 2) 27
3. Low back strain/pain (2 of 2) Answer : M54.5 4. Contact Dermatitis of the Eye Answer: H01.119 28
5. Ingrown toenail, right great toe Answer: L60.0 6. Mild intermittent asthma, status asthmaticus Answer: J45.22 29
7. Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (1 of 3) Answer, Part 1: H72.91 7. Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (2 of 3) 30
7. Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (3 of 3) Answer, Part 2: H66.3X1 Final Answer: H66.3X1, H72.91 8. Type 1 diabetes with diabetic nephrosis (1 of 2) 31
8. Type 1 diabetes with diabetic nephrosis (2 of 2) Answer: E10.21 9. Visit to change surgical dressing Answer: Z48.01 32
10. Dysuria Answer: R30.0 11. Well baby exam, without abnormal findings, aged 3 months Answer: Z00.129 33
12. Immunization for MMR Answer: Z23 13. Nursemaid s elbow, left elbow, initial encounter Answer: S53.032A 34
14. Anaphylactic reaction due to eating peanuts, initial encounter (1 of 2) 14. Anaphylactic reaction due to eating peanuts, initial encounter (2 of 2) Answer: T78.01XA 35
15. Long Term Anticoagulant therapy Z79.01 16. Screening for cholesterol Z13.220 36
17. Pre-operative clearance in patient with heart disease 18. Chronic Pain in right knee (1 of 2) 37
18. Chronic Pain in right knee (2 of 2) Summary ICD 10 Larger universe but similar process Expanded documentation requirements Capture (in writing & code) what you know Uncertain about code Expanding (fine tuned) favorite s list IMO (via EMR) On-line Options 38
Questions 39